Need for an HPV vaccine?

A decade after its launch in the global market, the debate around the HPV vaccine hasn’t settled. In India, public health experts still remain unconvinced about its efficacy

August 28, 2016 12:34 am | Updated 12:34 am IST

In this age of ‘Tinder’ dating, a vaccine that offers protection from the sexually transmitted human papillomavirus (HPV), which should be administered before first intercourse, may come across as an apt intervention. But 10 years after its launch in the global market, the debate around the HPV vaccine is far from over, with public health experts in India far from convinced.

While pharma giants showcase the vaccine’s uptake in various countries and also its inclusion in some national immunisation programmes (IP), oncologists and doctors in India’s public hospitals cite the drop in the incidence of cervical cancer without the vaccine figuring in the country’s IP. Their key reservation is that it is too early to determine the vaccine’s efficacy, and too expensive an intervention.

Drop in cases

“In the last two decades, I have seen the incidence of cervical cancer drop from 24 to 8 [per 100,000] in Mumbai. In the U.S., it is 7,” says Dr. Rajendra Badwe, director of the cancer hub Tata Memorial Centre (TMC). Annual registrations of new cervical cancer cases at the TMC have dropped to 800 from 2,200, two decades ago. A paper Dr. Badwe co-authored in the South Asian Journal of Cancer , notes that robust data from population-based cancer registries have shown that the incidence of cervical cancer in rural and urban India is decreasing. The paper notes that it is early days yet to measure the vaccine’s efficacy in preventing invasive cancer.

Improved personal hygiene, availability of running water in washrooms, and better nutrition have been cited as the cost-effective measures leading to the drop.

In India, 122,844 women are diagnosed with cervical cancer while 67,477 die from the disease annually. Two vaccines — Gardasil and Cervarix — are available in India. The first is quadrivalent and gives protection from not just HPV but also genital warts among other conditions. Cervarix is bivalent and offers protection from two HPV types.

But health experts are wary of including the vaccine in the IP. “There are other gynaecological concerns such as white discharge that screenings (pap smears) can pick up. They have more value,” says Dr. Veena Shatrugna, former deputy director, National Institute of Nutrition, Hyderabad. She notes that Malaysia and Bhutan, which have the vaccine in their IPs, have better health-care programmes. But in India, the vaccine could just be used as a shortcut for all things related to women’s health issues, leaving a host of other concerns unattended.

Proponents of the vaccine, including the World Health Organisation (WHO), have said that interventions such as screening and vaccination need to coexist and can even eliminate the cancer.

‘Screenings inadequate’

But officials of pharmaceutical giant, MSD Pharmaceuticals, that launched Gardasil a decade ago, say screenings cannot be equated with vaccinations. Dr. Anuj Walia, Regional Director, Medical Affairs (Asia Pacific) with MSD Pharmaceuticals, says women who go in for screenings may not maintain the three-year regimen of getting checked again. He adds that it is also likely for a cancer to not get picked up by a pap smear. “The vaccine gives protection for the next 10 years and its primary prevention is to avert the risk as against screening that is secondary prevention,” he says.

Gardasil costs Rs.2,700 per dose and WHO recommends two doses, in the 9-13 age group. It is for this that Dr. Y.S. Nandanwar, head of obstetrics and gynaecology at L.T. Medical College, Mumbai, equates the vaccine with cord blood cell banking — those who can afford can take it. He says the country has limited funds and public hospitals are fighting for basic equipment, so screenings and early detection can pack a punch in fighting the cancer.

The decision to vaccinate or not hinges on parents. Dr. Suchitra Pandit, past president of the Federation of Obstetric and Gynaecological Societies of India (FOGSI), is for the vaccine, but says, “Rather than speaking for or against the vaccine, we give people the choice and tell them to speak to their children about safe sex — the use of condoms and maintaining genital hygiene. This conversation has started in families and schools.”

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